No Such Thing as a Free Lunch

Not long ago I was contacted by an Associated Press reporter who asked for my help with an article she was writing on formula marketing by U.S. hospitals.  She asked me to provide contact information for women whose babies had either been given formula in the hospital or who were given formula marketing bags on discharge.  This was not hard to do, as according to the U.S. Centers for Disease Control and Prevention, 25% of breastfed babies receive unnecessary formula supplementation during their hospital stay.  And a recent article in Pediatrics estimates that 72% of U.S. hospitals distribute industry-sponsored formula sample packs to new parents  

Thanks to my online contacts, within 2 hours 12 local mothers had volunteered to talk to this reporter. I had high hopes, but the article was a disappointment.  Formula company spokespeople were given the last word, noting that “it’s good to have a back-up” and characterizing it as “irresponsible” not to give new mothers free formula in the hospital.   

What was not reported was the true cost of this “free” formula to parents and the impact of hospital formula marketing on breastfeeding.  The most recent study on the effect of hospital distribution of infant formula  found that the mothers who received formula samples at discharge were less likely to be exclusively breastfeeding during each of their baby’s first 10 weeks as compared with women who did not receive them.  For a summary of decades of research on this issue, click here.

What’s most important for parents to know, though, is that this is not just about breastfeeding.  The reason formula companies work so hard to establish these unholy alliances with hospitals is that they know from their own research that due to fear of adverse reactions, most parents will continue to buy the formula their baby is given first. 

The “free” formula included in those stylish marketing bags is each brand’s most expensive type.  A cost analysis done by the outstanding nonprofit organization Ban the Bags found that formula-feeding families who use the high-priced formula in these marketing bags will spend $700 more during their baby’s first year than if they bought the generic store brand.  This is the true cost of these bags to families.  No wonder formula companies are so anxious to get this product into their hands! 

What’s in it for hospitals?  In many cases, in exchange for acting as formula marketing agents (and therefore endorsers of infant formula) hospitals receive unlimited free formula for their use.  And when formula flows like water on maternity floors it’s more likely to be fed to newborns unnecessarily to the detriment of breastfeeding: a double benefit for the formula industry. 

How can we convince hospitals that it is inappropriate and unethical to give formula samples to new parents?  In many ways, as Ban the Bags points out, this practice is like giving out free Big Macs on the cardiac floor.  Babies who receive infant formula have poorer health outcomes and higher health-care costs than exclusively breastfed babies.  It makes far more sense for hospitals to focus their energies on marketing health, not commercial products.  Click here for some ideas from Ban the Bags on how to sell this idea to your local hospital.

One last thing.  If you received a formula marketing bag from your local hospital, don’t forget to write a letter of complaint to the hospital's administration.  Patient satisfaction has a huge effect on hospital policy decisions.  Use your influence for the benefit of all new parents.

Settling in to My New LLL Home

In a previous post, I described being booted from La Leche League (LLL) of IL, where I had worked as a Leader since 1982, for the crime of working as both a LLL Leader and a Breastfeeding USA (BFUSA) Breastfeeding Counselor.  My accreditation with another organization was not surprising.  Those who know me can testify that if breastfeeding is involved, you can count me in!

When I published my post, I was flooded with invitations from LLL Leaders and Area administrators who warmly welcomed me and extended their unconditional support.  So many people wrote that it was impossible for me to respond personally to them all.  If you were one, please accept my deepest thanks! 

Although I had many LLL Areas to choose from, I decided what was most important to me was not the quality of its beaches (as one Florida Leader offered as an incentive) but whether my presence was likely to bring the LLL International (LLLI) hammer down on my new Area.  I did not want to join a new team only to make their lives miserable by becoming a liability. 

So when I received an invitation from LLL of Connecticut, I knew that this was a match made in heaven.  These amazing ladies have become known for standing their ground against unreasonable LLLI policies and directives.  Of course, disagreeing with LLLI’s administration these days is almost guaranteed to result in sanctions and threats, so when the LLL of CT Area team made its concerns known publicly, LLLI wrote them a letter accepting their resignations, which they had not offered.  But LLL of CT has long been registered as its own nonprofit organization with the team as its legal representatives.  This allowed them to thumb their noses and continue their work.  They also bought their own liability insurance, so that could not be used as a weapon against them.  When LLLI tried to convince other CT Leaders to take their places, these Leaders made it clear that this team had their full support.

I have a feeling I’ll fit right in with LLL of CT, which just yesterday became my official LLL Area.  After all, as the saying goes, “Well-behaved women rarely make history.”  As you might expect, my opinion on the issue that led to my actions has not changed.  If anything, I am more convinced than ever that LLLI’s directive that Leaders must choose between LLL and BFUSA is divisive and therefore destructive to breastfeeding. 

In recent weeks, people on the inside have confirmed that the goal of this directive is to undermine BFUSA, which includes ex-LLL Leaders among its founders.  LLLI is headed down a slippery slope.  In Illinois, nearly half of its Leaders have resigned in the last two years.  It’s clearly time for it to look in the mirror and reevaluate its Leadership and its strategies.

I heard that one aspect of my actions was particularly upsetting to LLLI: my announcement on Facebook about my new BFUSA Breastfeeding Counselor status.  Should I take this to mean that it’s all right for LLL Leaders to be involved with both organizations as long as they don’t say so publicly?  Can we expect this to become LLLI’s version of “Don’t Ask, Don’t Tell?” 

If LLLI wants to grow and thrive, booting out those who question it is exactly the wrong approach.  LLL Leaders have never been easily cowed.  Those who breastfeed long term are clearly comfortable following a different drummer.  They are not women who can be bullied into following directives that are obviously wrong.  Take it from one who knows… or ask the Leaders in my new LLL Area.

The Swaddling Controversy Continues

You may have read my two previous posts in this blog's "Swaddling" section, which sparked a huge controvery among my readers.  My original post was an abridged version of the lead article I wrote for the September 2010 issue of the International Journal of Childbirth Education. 

After my article appeared, the editor received a letter from Dr. Harvey Karp, author of the popular book The Happiest Baby on the Block and its companion DVD.  Not surprisingly, Karp disagreed with many of my conclusions, as swaddling is the first "S" in his "5 S's" approach to calming fussy babies.  The journal editor kindly asked me if I would like to respond to Karp's letter, which I did.  You can read both Karp's letter and my response on page 26 of the Summer 2011 issue of the International Journal of Childbirth Education.

Feeling Supported

Thanks to everyone who has written me in support and sympathy as a result of my removal as an LLL leader from LLL of IL.  Your kind words have made a difficult situation more tolerable.

I’ve been thrilled to receive many offers from other Areas, both within the U.S. and internationally, to join their ranks and affiliate with them.  I’ve been assured that I would be welcome to serve in these Areas and that they have no intention of forcing their leaders to choose one breastfeeding organization over another.  It’s going to take me a little time to sort out the details, but I’ll make it public when I determine which will be my new Area.

In the meantime, I’m hoping we can right this wrong.  I encourage every La Leche League member and leader who agrees with me that a new liability insurance policy is in order to contact LLLI’s Board of Directors and make your opinion known.  Hopefully we can convince them of the destructiveness of making us choose one organization over another.  With enough support, we may be able to make La Leche League International once again an organization that supports all those who help breastfeeding mothers.   

Goodbye, LLL of IL

My crash-and-burn summer continues with the news tonight, delivered in person by my brand-new La Leche League Area Coordinator of Leaders (ACL), that despite my intention to continue as an Illinois LLL leader after almost 29 years, she is removing me from her roster.  Why did she take this action against my wishes?  Here’s the reason she gave:  I made it known that I recently became an accredited breastfeeding counselor with the new mother-to-mother support group Breastfeeding USA and I wanted to represent both organizations. 

You’d think that the loss of nearly half of Illinois’ leaders in the last 2 years would give her pause about eliminating leaders who are willing to serve.  I guess not.  She referenced La Leche League International’s announcement last spring that any LLL leaders who were affiliated with both LLL and Breastfeeding USA would have to choose one, because representing both would put its leader liability insurance at risk.  Yet oddly, the liability insurance through Breastfeeding USA does not carry this same prohibition.  It assumes the covered individual knows which organization she is representing.

Is LLLI looking into finding alternative liability insurance?  Word has it that earlier this week those at La Leche League International were given the opportunity to switch to another policy that does not require its leaders to make this choice and they opted not to do so.  It appears those in charge would rather kick out those who step over this line. 

My ACL had some choice words for me.  She told me that I clearly thought I was more important than other people. (Because I want to help breastfeeding mothers in more than one capacity?)  As she was leaving, she told me that although I am no longer an LLL leader in IL, I have the option of affiliating with another Area if any would have me, a possibility she seemed to think remote.

I told her that I consider this policy short-sighted and destructive of the greater good.  Until now, La Leche League International has always cultivated cooperative relationships with other breastfeeding organizations.  This is the first time it has created a policy that was openly antagonistic. 

To me, this is a serious problem.  The slogan of the Chicago Area Breastfeeding Coalition, which I helped to found, is “Strength in Numbers: Creating One Breastfeeding Community” and it exists to unite IBCLCs, LLL leaders, BFUSA breastfeeding counselors, peer counselors, doulas, physicians, midwives, everyone who comes in contact with breastfeeding mothers.  When we speak with one voice, we promote our cause more effectively.  When we undermine each other, we also undermine breastfeeding. 

I told my ACL that if my example will help to right this wrong and shine a light on this destructive policy, then I am willing to be the sacrifice.   We need to stand together and support one another, not tear each other down. 

La Leche League International, hear my words, you cannot afford to alienate more dedicated women!  And if you continue to implement and defend policies that undermine breastfeeding, you are not long for this world.

On Baby Time

As World Breastfeeding Week begins, I arrive home after almost 2 weeks in Atlanta spent helping my son Peter and his wife Ania as they cared for their new baby.  My grandson Jakub, their first child, is now 6 weeks old and doing beautifully.  We learned at Jakub’s 1-month pediatric visit that he had gained 2 lbs. in 2Peter & Jakub weeks, so there are no worries about breastfeeding.  Ania has become a real pro. 

After giving countless talks and writing many pages on the importance of having help during the first 40 days after birth, I was delighted to help my own family during this vulnerable time.  As the mother of 3 sons, I will always be the mother-in-law and never the mother, so being welcomed into their home after Ania’s mother left felt like a real blessing.

Being on baby time again brought back so many memories as I played, rocked, patted, walked, and talked to Jakub during his fussy times and while Peter and Ania got some extra sleep or ate a meal. Peter smiled as he watched me pour warm rinse water over Jakub’s head during his bath.  He shared that this evoked memories of having his own soapy head rinsed as a baby.  It was immensely satisfying to see my son take on the mantle of fatherhood with such confidence and ease.  It felt completely right to pass on this torch to the next generation. 

Now as I contemplate World Breastfeeding Week, my senses still tingle from the simple pleasures babies bring to our lives.  The soft skin, the sweet smell, the warm cuddles, and the miraculous way their simple existence triggers waves of love that radiate throughout a family.  TheA wonderful memory three of us could hardly take our eyes off Jakub.  Every movement and expression was endlessly fascinating. 

So for me, this week’s celebration is about the intimacy breastfeeding fosters.  This is what drew me to this profession and where—I believe-- breastfeeding’s true power lies.  So this week I again offer my thanks to everyone around the world who helps new parents birth and breastfeed their babies.   The future of our world depends on these newborns.  Let’s never forget that their birth and breastfeeding experiences will influence the kind of world they build.

My New Industry-Free Life

Last Friday my life changed drastically.  For the previous 8.5 years I worked full time at my day job as a lactation consultant for Ameda Breastfeeding Products.  In that role, I spent many hours on the phone talking to mothers about pumping and breastfeeding.

In 2008, I thought I might have to leave when Ameda was bought by Evenflo, a U.S. juvenile products manufacturer whose marketing practices at that time were in violation of the International Code of Marketing of Breast-Milk Substitutes, also known as the WHO or International Code.  This Code was created by the World Health Organization to protect breastfeeding from commercial influences by restricting the marketing of infant formula and feeding bottles.  In the U.S. adhering to this Code is strictly voluntary and baby bottles were the founding product in Evenflo’s line.

Abiding by the International Code is part of my profession’s Code of Professional Conduct, which I take very seriously.  I was shocked (in a good way!) when Evenflo's then-CEO told me of his intentions to bring the company into compliance with the Code.  So I decided to stay on and help.  Some of you may have heard me speak about our efforts—with the help of many Code experts from around the world—to change everything from Evenflo’s website content to packaging until Evenflo met its obligations under the International Code.  This historic effort helped raise awareness of the Code in the U.S. among both clinicians and industry.  It even caused the International Lactation Consultant Association, my professional organization, to change its advertising and exhibit hall practices.  As ILCA’s then-President told me, “What you did made us realize that the Code is meant to be a change agent.”

However, nothing stays the same.  CEOs came and went and sales of Evenflo’s infant feeding bottles declined.  It’s tough to compete when none of the other U.S. baby bottle manufacturers adhere to this Code and continue marketing their products.

A week ago Monday the word came down that Evenflo was changing its stance and would begin marketing its newly released baby bottles to parents on its website, through its social media channels, and in print ads.  Although Ameda—my own little division of the company—did not even make products covered by the Code, my paycheck came from Evenflo.  My choice was clear, but that did not make it easy.

Leaving Ameda is a major life event for me.  But as many have told me, when one door closes, another opens.   My first love is speaking at conferences and to groups, and now I have more time for that.  If you are looking for a speaker for your breastfeeding event, please keep me in mind.

Our Amazing Network

Yesterday morning my new grandson, Jakub Carl Mohrbacher, entered the world at 7.5 lbs.  After 24 hours of labor with her first baby, my daughter-in-law Ania realized her dream of a natural, unmedicated water birth.  One my gifts to her was the services of a labor doula, Ayla, who was invaluable to Ania in managing her contractions.

His first baby was my son Peter’s Father’s Day present this year

I feel grateful today to Ayla, Ania's nurse-midwife Margaret, and my entire birth and breastfeeding network.  I live in the Chicago area and my son Peter and Ania live in Atlanta.  Ania’s mother will be the first to arrive at in Atlanta on Thursday to provide round-the-clock help to the new family.  When she leaves, I’ll fly there to spend two weeks as their helper at the end of July.

In other words my connection to them in the last two days was strictly by phone, e-mail, Skype, and text.  But I played an active role.  When Peter told me Ania was initially having trouble getting little Jakub latched on well, I made a phone call to the lactation department of her hospital and asked them to please look in on her, leaving her room number on the message.  With their permission, Ruby, the hospital LC, was kind enough to call me and report back after she saw them.  Fortunately, Ania needed just a little tweaking to get Jakub nursing well.  When a resident walked into their room and mentioned the possibility of separating mother and baby, I began calling all the lactation consultants and peer lactation support people I knew in Atlanta to get a recommendation for a breastfeeding-friendly pediatrician they could request in the hospital.  That situation turned around quickly and now no separation is planned. 

I offered to schedule a home visit on Tuesday after hospital discharge with Claire, a private practice lactation consultant.  Peter gladly accepted this offer as a way to set their minds at ease. 

Today I extend my gratitude to Ayla, Margaret, Ruby, and Claire, to everyone I spoke to who gave me help and encouragement, as well as everyone else who touched the lives of my family.  I also give thanks for everyone everywhere who helps birthing and nursing families. 

As I did my best to help Peter and Ania navigate these hurdles and to smooth their way, I couldn’t help but also think of  the many new parents who are not connected to this amazing network and who struggle alone and unaided.  My fondest hope is that someday all new parents will get the help and support they needs.

Formula Supplements Put Mothers at Risk

We know that anything less than exclusive breastfeeding increases health risks for babies.  But what about mothers?  I often talk to breastfeeding mothers who decide to supplement their babies with formula because they assume they will get more sleep and that sharing feedings will reduce the stress of the early postpartum.  Most don’t realize this strategy actually has the opposite effect. 

In an earlier post, I reported on research that found exclusively breastfeeding mothers get more sleep at night than mothers who also feed formula, even when others handled some night feedings.  Now a new study1 takes this insight one step further by examining how formula supplementation affects the amount of sleep new mothers get, their risk of depression, their overall health, and their feeling of well-being.  During the early postpartum all of these measures profoundly affect a new mother’s enjoyment of her baby and her ability to cope. 

This study, which will appear in the June issue of the journal Clinical Lactation,surveyed 6410 mothers during the first year after birth.  Although all new mothers experience fatigue, it found thatexclusively breastfeeding mothers not only slept significantly more hours during the night than other mothers but also reported significantly more energy during the day, a better mood, better overall health, and a greater sense of well-being.  Another surprising finding was that there was no statistically significant difference in any of these areas between the mixed-feed and the exclusively formula-feeding groups. 

This means that rather than making a new mother’s life easier—which is often her goal—feeding her baby formula supplements can significantly decrease her quality of life.  The authors note that some popular books on postpartum depression recommend that after birth at-risk mothers sleep apart from their babies and let others handle night feedings.2  Some hospitals have even begun implementing this strategy among at-risk mothers before discharge.  Even more extreme, others recommend at-risk mothers avoid breastfeeding altogether as a way to prevent postpartum depression, despite the substantial evidence that breastfeeding mothers have a lower risk of postpartum depression.3

This new study indicates that although trying to help at-risk mothers get more rest after birth may seem to make logical sense, strategies that separate and supplement newborns are misguided.  They actually put mothers at greater risk of sleep disruption, depression, and poorer health.

References

1Kendall-Tackett, K., Cong, Z., & Hale, T.W.  The effect of feeding method on sleep duration, maternal well-being, and postpartum depression.  Clinical Lactation 2011; 2(2): 22-26.

2Bennett, S.  Postpartum depression for dummies. Hoboken NJ: Wiley Publishing, 2007.

3Dennis, C.-L., & McQueen, K.  The relationship between infant-feeding outcomes and postpartum depression: A qualitative systematic review. Pediatrics 2009; 123(3):e736-e751.

What's In the Bottle?

Scientists found that babies who are not breastfed have a 30% to 40% increased risk of childhood obesity.1 Milk intake and weight gain vary greatly among formula-fed and breastfed babies.  (For more, see my earlier POST.) Formula-fed babies consume 49% more milk at 1 month, 57% more at 3 months, and 71% more at 5 months.2 This significant difference in milk intake is due in part to how milk flows from breast and bottle.  Recent studies have examined these feeding differences in more detail to help answer the question “How is obesity risk affected when the feeding bottle contains mother’s milk?”  

The study mentioned above provides a partial answer.  Caregivers’ behaviors during bottle-feeding—which are independent of what kind of milk is in the bottle—influence babies’ intake.  For example, when bottles contain more than 6 oz. (177 mL), babies consume more milk.  Also, babies whose caregivers encourage them to finish the bottle are heavier than other babies. 

An important part of obesity prevention is the ability to self-regulate what we eat to match our energy needs.  Breastfeeding naturally teaches babies this self-regulation by giving them more control over feedings.  While breastfeeding, baby must actively draw milk from the breast.  He learns to take milk when hungry and stop when full.  This helps baby become attuned to his body’s hunger and satisfaction cues.  During bottle-feeding, baby’s role is more passive.  Fast, consistent flow and regular coaxing to take more milk, even when full, can lead to a habit of overfeeding and poor self-regulation. That's why if your baby will be bottle-fed often, rather than just laying baby back and tilting the bottle up, use the pacing techniques described HERE.

In one study of 1250 U.S. babies, researchers used bottle-emptying as a measure of poor infant self-regulation.3 (An earlier study verified this link.4) It didn’t matter whether expressed milk or formula was in the bottle.  The more often the babies were fed by bottle during their first 6 months, the more likely they were to empty the bottle during their second 6 months.  Only 27% of the babies who were exclusively breastfed during their first 6 months emptied the bottle during their second 6 months.  Of those fed at first by both breast and bottle, 54% later emptied the bottle.  Of those fed at first only by bottle, 68% later emptied it.

Mother’s milk plays a vital role in a healthy beginning.  But as these studies demonstrate, there is more to breastfeeding than the milk.  Even when mother’s milk is in the bottle, regular bottle-feeding can increase a baby’s risk of childhood obesity. One way we can offset this effect is to make bottle-feeding more like breastfeeding using pacing techniques, which hopefully will decrease the risk of overfeeding.

References

1 Dewey, K.G., Infant feeding and growth.  In G. Goldberg, A. Prentice, P.A. Filtreau, S., & Simondon, K. (Eds.)  Breastfeeding : Early influences on later health (pp. 57-66).  New York, NY: Springer.

2 Kramer, M. S., Guo, T., Platt, R. W., Vanilovich, I., Sevkovskaya, Z., Dzikovich, I., et al. Feeding effects on growth during infancy. Journal of Pediatrics 2004; 145(5): 600-605.

3 Li, R., Fein, S.B., & Grummer-Strawn, L.  Do infant fed from bottles lack self-regulation of milk intake compared with directly breastfed infants?  Pediatrics 2010; 125(6): e1386-e1393.

4 Li, R., Fein, S.B., & Grummer-Strawn, L.M.  Association of breastfeeding intensity and bottle-emptying behaviors at early infancy with infants’ risk for excess weight at late infancy.  Pediatrics 2008; 122 Suppl 2: S77-S84.

My Prolific Week

It has been exciting to see the debut this week of two articles I wrote last fall.  The first article appeared in La Leche League International’s online magazine for mothers, Breastfeeding Today.  It describes answers recent research has provided to common questions about nipple shield use.  Nipple shields are a breastfeeding tool many mothers love to hate in part because of the inconsistent answers they receive about them. Thankfully, we now have some objective information on these gray areas.

The second article appeared in the current issue of Clinical Lactation, the journal of the United States Lactation Consultant Association (USLCA).  Written for professionals, this article describes teaching strategies that can be used with mothers who are employed or exclusively pumping to help clarify how milk production works.  It draws from some of the posts in the For Employed Mothers section of this blog.  If you help mothers in these situations, have personal experience, or just want to learn more, please take a look.

We Are Breastfeeding

I had the privilege of meeting April Foster, the author of this post, when I spoke in Napa, California on January 20.  After my talk, “Transitioning to the Breast,” April approached me to tell me that many of the strategies I described had worked for her and her son, who she adopted at 20 months.  When she told me her story, I asked her to share this amazing saga of love and devotion.  April’s sons are incredibly lucky boys! --Nancy

I have a son that came to us through adoption at 20 months of age. We started our breastfeeding relationship about 4 weeks after placement in our home. Our journey is astonishing, especially for those new to adoptive breastfeeding.

Almost any woman can induce lactation through breast stimulation with a breast pump or by just putting a baby to the breast to suckle. The hormones cause the milk ducts to start making milk. Mothers often question how much they will produce.  But the amount of milk I made is not what was important to me. I April and Andrewknew I would adopt a baby older than 12 months, so this did not concern me as much as it would if my child had been an infant.  

I had heard about adoptive breastfeeding for years, but since I was adopting an older baby, I assumed it wasn’t possible. I had already grieved the loss of having children by birth and had come to terms with never having a breastfeeding relationship with my children. This was okay with me. Then one day in an adoption search I saw a story about a wonderful breastfeeding relationship between a mother and baby who was adopted at about 2 years of age. I thought, “You have to be kidding me! How is this possible? What about the ‘nipple confusion’ I had heard so much about? How do you teach them to do it? And what impact does that have on their mind and soul? How would my friends and family react?” This would certainly be a strange thing to do. It turned out my friends and family were happy and supportive.  And breastfeeding my adopted baby felt completely natural. Many mothers find this a wonderful way to bond with their adopted children.

I decided to try inducing lactation, and started by pumping 5 to 8 times a day for about 10 minutes. The first day I only produced a few golden yellow drops. The next day I saw white milk but did not make much. At the end of 3 months I was only pumping about 1 to 2 ounces (30 to 60 mL) a day. It may sound crazy that I was pumping so much and getting so little milk. I kept reminding myself that getting a lot of milk was not my goal. I was preparing my breasts for suckling and stimulating milk for my baby. I was excited that my breasts were making any milk at all and amazed this was possible!

Then one day we got the call and went to pick up our children: two brothers 20 months and 3 years old. They told us my 20-month-old was not taking a bottle, but I had already purchased some bottles in preparation, so I thought I would try re-introducing it to him. I was unsure if he would want to breastfeed, but we would try and if he decided not to, that would be okay.

He loved the bottles of milk! They were one of the few things that comforted him at first. His hands held the bottle tightly as if someone was going to take it away. During the first few days, my son would not let me touch him. He only wanted to be held by my husband, who he gave him the bottles. This was heartbreaking after all my preparation, but I was also prepared for this and didn’t take it as a rejection. I knew he would come around. The first two nights he was up almost all night. The bottle would put him to sleep, but taking the nipple out of his mouth woke him. Moving him woke him and he woke within an hour of sleeping. He was scared and in a strange house with strangers all around. How in the world was breastfeeding ever going to work? He wouldn’t even let me hold him.

After a few days, I decided to sleep with him on the kitchen floor so I could get the bottles fast and my husband could sleep. My son still woke screaming. The bottles helped, but they didn’t always work. Then we decided only I would give him food and all bottles would come while I held him in my arms. This meant no high chair at dinner, no snacks he could hold himself, and no bottles while walking around. When he took a bottle, he wouldn’t look at us. He wouldn’t let me touch the bottle. I think he was scared someone would take it away. He wanted to keep the nipple in his mouth even in his sleep. This was a good sign he would like breastfeeding once we got there.

I did everything I could to get close to him during the first few weeks, rocking, walking with him, holding, co-bathing, co-sleeping. Any kind of skin-to-skin contact did us good. At first my 20-month-old wouldn’t let me put my hand on him while sleeping. He would wake up immediately and push my hand away, because he was used to sleeping in a crib all by himself. Within the first week, he let me put my hand on him for short times. I tried to stay close to him all day while he played and put my hand on him whenever he would let me. We still had moments when he would scream and cry, run away, and want me to leave the room. He would cry for hours. But it was expected and normal for him to be upset and mad that his whole world had been turned upside down. These moments always ended with him finally taking a bottle with me and going to sleep. We were getting closer, and he was getting to know that he could trust me, but it was slow going. I was up almost all night long but loved every minute of it. I remember one day sending an e-mail to my mom and sister at 5:00 am telling them that I hadn’t slept but that I was crying because I was so delirious with happiness. It had been one of the good nights when we played and laughed and cuddled and rocked with bottles with only a few bad episodes. It was getting better every night! 

I also talked to both of my kids about mommies and babies nursing. We would have the baby ducks nurse from their mommies in the bathtub. We would read books that had animals nursing. Both of my kids loved to play with their animals and dolls and to nurse them. This was a good way for my 3-year-old to learn how a mommy is supposed to take good care of her children.

After about 2 weeks, my 20-month-old finally started waking up looking for me, happy to see me instead of screaming. I put my hand on him more and more while he slept to get him used to the feeling of a warm body near him. One time he woke up, saw I was there, and went back to sleep. When giving him bottles in my arms, he started to let me hold him while lying down. The bottle still faced slightly away from me, but he could look at me now. I starting taking off our shirts for more skin-to-skin contact, and also so his face was next to my breast and he could feel and smell it. He still held the bottle really tight and wouldn’t let me hold it, so it was difficult to take it from him after he fell asleep.  I started wrapping the bottle in a big piece of soft material to give him something soft to hold onto but not to look at while the milk flowed. This worked. When he fell asleep, his hands fell gently away from the material.

During the third week, I began put the tube of an at-breast supplementer next to the bottle nipple. I planned to put this tube next to my nipple while breastfeeding so he could get more milk at the breast.  He needed to get used to that idea, so I pulled the tube through the bottle nipple with a needle, and then filled the supplementer bag with milk. Now the bottom of the bottle was no longer needed and the material hid the fact it was missing. I thought the slower flow of the supplementer might create anxiety, but he didn’t seem to notice the difference.

He was now used to sitting down with me for milk and began pointing to the refrigerator when he wanted some. He also started playing with my face and hair and laughing while drinking. Occasionally he wanted to sit and drink milk if he was upset or hurt. 

At the end of the third week I put the bottle nipple closer to my breast and then right over my breast.  Then I could move him toward me into a breastfeeding position. We were almost breastfeeding even though he had not yet latched on. He got milk from me while being held in my arms. He felt my skin next to his belly. He felt my breast against his cheek. He looked into my eyes. He smiled back at me. He got to know my smell and trusted that I would comfort him and give him nourishment when he needed it. He played with my other breast with his hand and my hair, nose, eyes, and mouth.  He put his leg up so I would play with his foot and make him laugh. He fell asleep while rocking in my arms. This is what breastfeeding is all about! If we stayed like this forever, and never actually breastfed, I would still be in heaven!

During the fourth week he was really happy and content, so I decided to offer my breast with the supplementer tube next to it. It felt different.  He was confused and didn’t want it. But when he was asleep, I tried offering my breast and he took it, sucking for about 5 minutes. Hurray! And wow, what a strange feeling. This was certainly different than the pumping I had done for 4 months. We were breastfeeding, even if it was only in his sleep.

Then there were a couple of bad days. He woke screaming again in the middle of the night and didn’t want the bottle nipple with the tube. He pushed both my husband and me away and wanted to cry by himself. This gave me doubts.  Maybe all these changes happened too fast, so I didn’t offer my breast again for 3 or 4 days. After a few days of this, he was happy with the bottle nipple and tube again and awoke happy to see me. I decided this probably had more to do with his grieving process than with breastfeeding.

So, at the end of the fourth week, I tried offering my breast more often when he was already asleep and rooting for the bottle. These moments didn’t happen very often, so I decided to try when he was awake. He seemed confused and didn’t want to take my breast. This was really tough for a couple of days. I always had the bottle ready in case. He took the breast a couple of times, but not for very long, and seemed confused at its different feel. Every time we tried my breast, my heart would race. I was nervous and anxious, which I think affected him. After 3 or 4 days, we both settled down and he started to get used to it but still preferred the bottle nipple if he could see it. So, I tried one day of offering my breast without the bottle nipple in sight. Eventually he took my breast, and as long as there was milk flowing, he was happy.

From that moment on, we were breastfeeding. It took a little over 4 weeks to transition him from bottle to breast, but he loved to suck and to breastfeed. I continued to use the supplementer, since I had no idea how much milk I was producing. I tried a couple of times without it, but he wasn’t happy. Someone asked if I thought it was because of the tube, which I had gotten him used to or because of the milk that was flowing. I had no way of knowing except…I could put the tube on my breast but crimp it so there was no milk flow. When I did this, he sucked just the same as he did before. This meant one of two Aprils sonsthings. Either, I was producing enough milk to keep him satisfied. Or, he liked to suck to pacify himself and didn’t care if there was a fast flow of milk. Either way, he was happy and I was happy. But, then I worried that maybe after a while of not getting enough milk, he might stop being happy with it, so I went back to the supplementer as a safeguard.

After about 3 weeks, one day I lost one of the supplementer parts and he breastfed just as often and just as long. We never used it again. It was such a relief to breastfeed without having to fill the bags or go to the refrigerator. He could then breastfeed wherever and whenever he wanted.  He caught on fast and asked to nurse often. His suck soon became much stronger. This increased my milk supply more than when we used the supplementer.

Sometimes I still wondered if this was good for my baby or if I was pushing something on him that he didn’t need or want. That question was answered when he had a fever for 3 days and then fell and cut his lip. He pointed to his lip and cried. The only thing that made him feel better was nursing. He asked to nurse every half hour during the day. He woke up every hour at night, and breastfed. He This was the answer I needed.

About 2 months after placement and 1 month into breastfeeding he sometimes woke just to check if I was there, breastfeed for about 3 minutes and peacefully went back to sleep. He did this about every 45 minutes. It was a great way for us to bond and attach, and for me to let him know that I was here for him whenever he wanted me.

He breastfed about 4 or 5 times at night and for 45 minutes first thing in the morning, sucking a little every few minutes. During the day, he breastfed more than I ever expected and I was thrilled with how much he liked it! It felt like he was an infant breastfeeding. I was also glad that some of those sessions were comfort sessions, lasting only about 2 minutes. Almost no one does this with a bottle. By the time you get a bottle ready, the moment is over. We breastfed in the living room, in the bathtub, at a restaurant, and by the side of the road. Some said I could have fulfilled my son’s need for bonding with hugs and kisses and other types of physical gestures. I say that my baby has all those and breastfeeding. What a nice addition to all those other wonderful things to make your child feel secure and loved. It may not be necessary, but it is precious.

We are now 8 months into breastfeeding. We still breastfeed every night to go to sleep and as soon as he wakes up. He now only wakes once at night to breastfeed. Some people told me that if I let him wake in the night so many times, it would last forever. He now sleeps peacefully, knowing that I am right there beside him if he needs me. Instead of cringing when I put my hand on his back, he rolls over and snuggles right next to me. Sometimes he wakes up and just wants to see I am there, rolls closer to me, grabs my hand and puts it around him and falls back asleep. This is bliss! He breastfeeds 5 to 10 times during the day, depending on where we are and what we’re doing. We will continue breastfeeding wherever and whenever he wants and for however long he wants, until he decides he doesn’t like it or need it anymore.

Some have asked if I have neglected my 3-year-old because I spent all this time with my 20-month-old. I think this experience has been great for him as well. My 3-year-old seemed comforted seeing a mommy taking really good care of his brother. He told me stories of when other mommies left his brother in a crib crying while he was scared. He now walks around and pretends to breastfeed his babies or brings them to me and says they want milk. He puts them to sleep and is very gentle with them. This is one of the most adorable things I have ever seen.

In the end, even after all the hard work, I know I had it easy compared to what I was prepared to do. Some women have taken many months to go through these same transition steps. I cannot say how happy I am to have stumbled upon something this wonderful. Had I not planned to breastfeed, I probably would have been happy that he was not taking bottles anymore. Who wants to fill bottles all day and wake up at night to fill them? How would we have bonded? How would he ever feel safe in my arms? We bonded with each other through this wonderful experience. I know we would have bonded eventually, but I am sure this way it happened much sooner.

Baby Friendly Hospitals Will Improve Black Breastfeeding Rates

This guest post comes from a fellow blogger, Elita.  It describes how a hospital’s Baby Friendly status affects breastfeeding initiation rates among Black mothers.  Similarly, a 2006 Australian study found that when breastfeeding rates there reached “universality” (in this study 96%), mothers of all ethnicities, education levels, and socio-economic status breastfed at the same rates.  In other words, once our institutions truly support breastfeeding, all women breastfeed equally.  Not surprising.  After all, we are mammals. --Nancy

A new update on California's breastfeeding rates and hospital policies was released by the California WIC Association and the UC Davis Human Lactation Center. The report, titled "One Hospital at a Time: Overcoming Barriers to Breastfeeding" takes a look at how instituting baby-friendly practices at Photo credit: edenpictureshospitals through California has impacted the breastfeeding rates.

California is currently home to 34 of the 150 hospitals and birth centers that have been certified as Baby Friendly by UNICEF/WHO. The report paints a very clear picture of how beneficial the Baby Friendly initiative has been to California's breastfeeding rates. Not surprisingly, the hospitals with the lowest breastfeeding rates are those that serve low income women of color and throughout the state, disparities are evident. The report states that in the past, these disparities were chalked up to differences in cultural practices, but the data clearly shows that hospitals that have baby-friendly policies in place were able to greatly reduce those disparities.

The report shows that the breastfeeding initiation rate throughout California for African-American women was at about 78% while the exclusive breastfeeding rate was around 40%. When you look at the exclusive breastfeeding rate for African-American women at the Baby Friendly hospitals, that number jumps from 40% to 60%. And although those numbers are still too low, they are far and away better than the national initiation rate of 54%.

We can also see the benefit of the Baby Friendly Hospital Initiative to African-American women in another state, New York. In New York City, all public hospitals are managed by Health and Hospital Corp., or HHC. HHC has encouraged its hospitals to incorporate all of the Ten Steps to Successful Breastfeeding, but only one, Harlem Hospital, has been certified as Baby Friendly.

Harlem Hospital serves a large population of African-American and African immigrant women. Any hospital that thinks becoming certified would be too difficult or wouldn't work with their population, need only look at Harlem Hospital as proof that it can be done anywhere. In 2007, right before officially becoming Baby-Friendly, 81% of women were breastfeeding when they left Harlem Hospital.

In a recent article in Heart & Soul magazine, a black woman who gave birth at Harlem Hospital talked about her experience. Alicia Lewis-Howard was told by family and friends that breastfeeding would hurt and she didn't think she would nurse for more than a month, but ended up breastfeeding for 6. She credits the nurses at the hospital with showing her how to properly latch the baby on so breastfeeding was not painful and for educating her on the many benefits of breastfeeding both to herself and her baby.

The Baby Friendly Initiative has been proven to increase black breastfeeding initiation and exclusivity rates. It is imperative that healthcare facilities that serve a large population of African-American women begin implementing as many of the Ten Steps as possible. Although the process of becoming Baby Friendly is extremely rigorous, there is no reason that hospitals can't make the smaller changes, like ensuring that all women are breastfeeding within an hour of birth and rooming in with their babies. If we want to see black breastfeeding rates improve, we have to see hospital practices improve. If California and New York can do it, why can't everyone else?

Marissa's Story: Empowerment in Action

“Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.”  --Margaret Mead

How does change happen?  Sometimes it takes just one person to be the catalyst.  One example is the developing Mother’s Milk Bank of the Western Great Lakes, whose major mover-and-shaker happens to be a mother from my Leche League group.

Her name is Marissa and she began attending my group when her daughter Aria was a baby.  Employed full time as a project leader, Marissa benefited from hearing other employed nursing mothers’ experiences at meetings.  Breastfeeding went smoothly with Aria.  Not so with her second baby. 

At 37 weeks of pregnancy, Marissa’s high blood pressure raised concerns about preeclampsia and led to the decision to induce.  Marissa wrote:

“On May 1st, at 3:23 am, our beautiful baby boy Lennon was born, clocking in at 4 pounds, 5 ounces (1956 g). Within 30 minutes, Lennon was nursing and snuggled skin to skin with mama. After an hour or more, the nurses did a blood test and identified his blood sugar levels as low. They brought me a bottleMarissa & Lennon in the NICU of formula and instructed me to give him the formula to try to boost his blood sugar. A few minutes later he was taken to the NICU for monitoring and treatment.”

The nurse told Marissa that Lennon would be fed formula on a 3- to 4-hour schedule and that she was welcome to feed him the bottle.  When she asked if she could breastfeed him, the nurse told her no, it would take too much energy in his weakened state and the time breastfeeding would take would interfere with the feeding schedule.

Marissa began pumping to encourage more milk flow.  The next day she was told she could breastfeed Lennon after he was bottle or tube-fed formula, but he was usually asleep or disinterested after being given so much formula.

Lennon spent his first 6 days in the NICU until his blood sugar levels stabilized.  During this stressful time, Marissa discovered that some nurses were more open to breastfeeding than others.  Some let her breastfeed before the formula feedings.  Others did not, even banning the lactation consultant from the NICU, when she agreed to help Marissa learn to use an at-breast supplementer to provide formula at the breast.

Marissa learned that at that hospital NICU, whether a baby was critically ill or like Lennon had a milder condition, the staff’s actions and the hospital’s policies actively discouraged breastfeeding. 

After hospital discharge and over time, Marissa began to question her experience.  She wondered why the hospital recommended formula for at-risk babies instead of providing donor human milk, which leads to better health outcomes.  She asked me and others in our local breastfeeding community why we hadMarissa and Lennon now no local milk bank.  

There was no good answer to that question.  Chicago had no milk bank because no one had yet made it happen, so Marissa decided to become its driving force.  With her experience as a project leader, she had the perfect skill set.  Within a few months, she rallied those of us in Chicago who shared the dream and met with a Wisconsin organization that had been a donor milk depot for the Ohio milk bank since 2005.  She successfully pulled us together into a passionate, cohesive group focused on bringing our developing milk bank to fruition.

When faced with a wrong that needs righting, what can one person do?  Many of us underestimate our ability to make a difference.  Marissa’s story is one example of how one person really can change the world.

Should Solid Foods Be Started Earlier Than 6 Months?

Many breastfeeding advocates were startled by the worldwide press given to an article that appeared last week in the British Medical Journal.  Its authors suggested that the evidence for exclusive breastfeeding for the first 6 months of life is less than compelling.  And they shared data that caused them to question whether starting solids between 4 and 6 months of age might be a healthier alternative for families in affluent countries. 

Is this recommendation from the World Health Organization (WHO) really out of date?  Should it be revisited?  In response, Randa Saadeh of the Department of Health and Development at WHO headquarters in Geneva, Switzerland released the following statement:

"WHO's global public health recommendation is for infants to be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health. Thereafter, infants should be given nutritious complementary foods and continue breastfeeding up to the age of 2 years or beyond.

"WHO closely follows new research findings in this area and has a process for periodically re-examining recommendations. Systematic reviews accompanied by an assessment of the quality of evidence are used to review guidelines in a process that is designed to ensure that the recommendations are based on the best available evidence and free from conflicts of interest.

"The paper in this week's BMJ is not the result of a systematic review. The latest systematic review on this issue available in the Cochrane Library was published in 2009 ("Optimal duration of exclusive breastfeeding (Review)", Kramer MS, Kakuma R. The Cochrane Library 2009, Issue 4). It included studies in developed and developing countries and its findings are supportive of the current WHO recommendations. It found that the results of two controlled trials and 18 other studies suggest that exclusive breastfeeding (which means that the infant should have only breast milk, and no other foods or liquids) for 6 months has several advantages over exclusive breastfeeding for 3-4 months followed by mixed breastfeeding. These advantages include a lower risk of gastrointestinal infection for the baby, more rapid maternal weight loss after birth, and delayed return of menstrual periods. No reduced risks of other infections or of allergic diseases have been demonstrated. No adverse effects on growth have been documented with exclusive breastfeeding for 6 months, but a reduced level of iron has been observed in developing-country settings."

Reference

Fewtrell, M., Wilson, D.C., Booth, I. Parsons, L., and Lucas, A.  Six month of exclusive breast feeding: How good is the evidence?  BMJ 342:c5955 doi:10.1136/bmj.c5955.

Where Do Milk Banks Fit In?

During my early years in breastfeeding, I found the idea of milk banks intriguing but less than exciting. To me, the rubber gloves, the lab equipment, and the rest of their high-tech gadgetry were positively off-putting.  All that changed when I attended a conference of the Human Milk Banking Association of North America.  There I finally understood the bigger picture and realized that milk banks play a vital role in a breastfeeding culture. 

To better grasp this role, it helps to know the World Health Organization’s ranking of infant feeding options from healthiest to least healthy.  Healthiest is, of course, direct breastfeeding.  Second is mother’s own expressed milk. Third is donor human milk.  And fourth is infant formula.  

Donor milk can make the difference between life and death, especially among preterm and ill babies.  Although many mothers work hard to try to provide their at-risk babies with their milk, research has found that more than half of mothers expressing milk for preterm babies have inadequate milk production by Week 6.1

This is a problem because very preterm babies are at risk of acquiring a serious condition called necrotizing enterocolitis, NEC for short, and feeding infant formula increases this risk.  When a baby acquires NEC, part of his digestive tract becomes inflamed and dies.   About 1 in 5 babies who acquire NEC die from it.  According to the Centers for Disease Control and Prevention, in the U.S. NEC is the cause of nearly 2% of all infant deaths.  Babies with NEC suffer horribly and the cost of treating it is astronomical.2Babies whose NEC is severe enough to require surgery are also at risk of long-term growth delays and neurodevelopmental problems, which can affect a family and a society for a lifetime.

This is where milk banks come to the rescue.  Research has found that only 1.5% of babies fed mostly human milk acquire NEC, as compared with 10-17% of babies fed exclusively formula.3So as the Swedes have already learned, the answer to this terrible scourge is to feed preterm babies only human milk during their hospital stay.  In Sweden, no hospitalized preterm baby receives infant formula before discharge.  If a mother cannot express enough milk for her baby, donor milk is given.

Milk banks provide a safety net for mothers unable to express all the milk their babies need. While direct breastfeeding is best and mother’s own expressed milk is second best, donor milk can be a lifesaver for babies whose only other option is infant formula. 

This ray of hope is why I became a member of the leadership team of the group pictured here, which hales from Illinois and Wisconsin and is working hard to establish the Mothers’ Milk Bank of the Western Great Lakes.  Our plan is to move heaven and earth to begin providing donor milk to babies in our states, where no milk bank currently exists.  An important role of this—and any—milk bank will be to educate hospitals about human milk as the standard of care.  Even with research backing, changing practice always takes time.  But it will be well worth the effort.  Our new website will be premiering soon and I’ll post a link when it’s ready.  Please wish us luck!

References

1 Hill, P. et al.  Comparison of milk output between mothers of preterm and term infants: The first 6 weeks after birth.  J Hum Lact 2005; 21(1):22-30.

2Bisquera, J. A., Cooper, T. R., & Berseth, C. L.  Impact of necrotizing enterocolitis on length of stay and hospital charges in very low birth weight infants. Pediatrics 2002; 109(3): 423-28.

3Sisk, P. M., et al. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. J Perinatol 2007;27(7), 428-33.

Responses to 'Rethinking Swaddling'

My December 3 post, “Rethinking Swaddling,” attracted more than 7,000 hits—a new record—and triggered many strong reactions.  For some, this post met a need; for others, it struck a nerve.  After reviewing the research, its central question was:  Does swaddling really calm babies, or does it stress them to the point of shutting down?

Readers responded with more than 50 comments here and on Facebook.  One wrote: “My paradigms are shifting at an alarming rate!”  Many understood the concern: “As a hospital lactation consultant, about 50% of my time is spent unswaddling and derobing babies and placing them on their mothers’ bare chests…Parents marvel at how I supposedly got a baby to latch who wouldn’t before.”  “I would like to see the readouts of blood pressure, brain patterns, heart rate, temperature, etc.” And: “I remember a professor telling me she used a certain DVD to teach what ‘shut down’ looked like in a newborn.”

Many disagreed strongly.  Some believed—despite the research findings—that because swaddling appears to calm babies that babies “like” or “prefer” it.  “It’s not me who insists on the swaddle, but it is really my baby who wants it.”  “Some [babies] prefer swaddling, others prefer to be free to move.” Many referred to swaddling as a way to “make babies happy.”  But returning to the question: Are swaddled babies really “happy” or are they shut down?  One thoughtful writer suggested: “it might be a great experiment to swaddle newborn puppies and kittens and see what happens, but probably animal rights activists would have my hide!”

Although avoiding swaddling right after birth made sense to most, some discounted the findings that swaddled newborns lost more weight and had lower temperatures.  They believed that because their swaddled newborns breastfed without problems or because the baby they didn’t swaddle lost more weight initially than the one they did swaddle, the research must be “wrong.”  Of course, there are many factors at work, and swaddling is just one of them.  It takes many more than one or two babies to accurately measure the effects of any practice.

Some were concerned about “the consequences of not swaddling.”  Without it, one wrote, “we would be seeing infants who are fussier, sleep less, and wear parents out more in the weeks following birth.  Temptation will be to put them onto their tummies to sleep, increasing their risk for SIDS significantly.”  Another wrote:  “My guess is that swaddling has saved many infants from shaken baby syndrome (after extended crying bouts) and also allowed babies who have never been willing to sleep on their backs before to accept this practice (if they are not co-sleeping and bedsharing families).”

Swaddling and sleep was the subject of many comments.  Several who were not bedsharing said their babies “needed to be swaddled to go to sleep.” One wrote that the biggest benefit of swaddling was “to encourage a baby to sleep on their back as per the AAP’s recommendation.  It is unfair to me to give parents a recommendation for safety, and then not offer them tools to help them follow those instructions.” Another wrote: “If parents didn’t have unreal expectations or believe infants are meant to sleep all night in their own space at a few weeks old…they would cope much better.” 

One wrote: “Swaddling helped immensely with putting him down to sleep after his needs had been met.”  Biologically speaking, though, body contact is not just an optional “nice to have.” Like milk, it is one of a baby’s needs.  Breastfeeding Made Simple explains that of the four categories of mammals, humans are considered “carry mammals.”  Like the other carry mammals—such as the great apes and marsupials—constant holding and feeding during the early months are the biological expectations of our young.  Has swaddling become a culturally acceptable substitute for the body contact our babies expect?  One writer suggested that swaddling can be okay if parents are alert to their baby’s cues, but another responded: “Swaddling suppresses the baby’s cues...so no amount of responsive monitoring can see cues that aren’t there.”  Or as one so succinctly put it:  “Humans are meant to be close to mum, not at arms length being shushed at.”

One considered the article a “blanket statement against swaddling” and an “all or nothing” approach “based on opinion and not actual facts.”  Another thought the post attempted to “take away a tool that many parents find so helpful and needed.” She contended that most parents only use swaddling as last resort after trying many other things first.  However, more than a few popular books and DVDs suggest swaddling as a first strategy to calm a fussy baby. 

Most would agree with the comment “We need to empower parents to read the research second and to read their babies and their own intuition first.”  However, if parents are told repeatedly that swaddling makes their baby “happy,” this colors their interpretation of their baby’s response.  Shouldn’t parents know that swaddling may be stressful for their baby?  Anything less than full disclosure is patronizing.  Only by hearing both sides can they make informed choices about this practice.

Another writer defended the post, noting “I don’t think the purpose of the article was to say swaddling should be thrown out altogether….It reads, ‘when babies get fussy, it may be best to limit swaddling and suggest instead parents consider alternatives, such as skin-to-skin contact and baby carriers.’”  This seems like a logical approach until we learn more about swaddling’s effects on babies.

Finally, a writer cautioned against limiting swaddling because it is an “age-old practice” that has been “used for centuries.”  However, the same could be said of discarding colostrum as “dirty,” an age-old practice in many cultures. We have since learned better.  And if we discover with further research that rather than calming babies, swaddling actually does stress them, we may need to rethink this practice as well as many of our own assumptions about it. 

Should All Breastfed Babies Have Above Average Weight Gains?

Just like in the fictional Minnesota town of Lake Wobegon, where “all the children are above average,” many parents believe there is something wrong if their breastfeeding baby’s weight isn’t above the 50th percentile.  While it is human to want our children to excel, the assumption that babies at a higher weight percentile are healthier or somehow “better” reflects a basic misunderstanding of growth charts and what they mean.

The purpose of a growth chart is to plot a baby’s growth on a series of percentiles, with the average baby at the 50th percentile.   What this really means in terms of weight is that out of 100 children, 49 will weigh less and 50 will weigh more. A weight that falls at a higher percentile is not “good” and a weight that falls at a lower percentile is not “bad.” By definition, there will be healthy children at every percentile.  Some will be chunky and some will be petite, but their percentile does not necessarily reflect their overall health or growth. 

A child at the 5th percentile is not necessarily growing poorly and the child at the 95th percentile is not necessarily growing well.  That’s because growth can only be evaluated over time.  For example, a preterm baby born very small will likely fall on a low percentile for weight at first, even when he is gaining weight well.  Also, if during pregnancy a mother had high blood sugar levels, gained a lot of weight, or received lots of IV fluids during labor, her baby’s birth weight may be unnaturally high.  In these situations, after birth a large baby may fall in percentiles to a weight closer to what his genes naturally dictate.1

But parents are not the only ones confused.  A U.K. study2 examined both mothers’ and healthcare providers’ perceptions of growth charts, and found that many mothers worried about their baby’s weight gain between checkups and that both mothers and healthcare providers erroneously considered the 50th percentile a goal to be achieved.  When babies fell below the 50th percentile, healthcare providers often recommended the mothers give their babies formula and solid foods to try to boost baby’s weight gain to reach this “desirable” percentile.  The researchers concluded that healthcare providers need more training on how to assess the growth of breastfeeding babies and how to support breastfeeding rather than undermine it.

Normal growth means a baby is gaining weight at a healthy pace and growing well in length and head circumference.  One point on a baby’s growth chart should never be considered in isolation but rather compared to other points.  It’s a baby’s growth pattern over days, weeks, and months that provides an accurate picture of how breastfeeding is going.  If a baby is growing consistently and well, his actual percentile is irrelevant. 

If over time, however, his weight-for-age percentile drops, first it’s important to determine whether the chart is based on breastfeeding norms, as many are not.  (Click here for the World Health Organization’s growth charts based on exclusively breastfed babies.)  If the chart is based on breastfed babies and the baby’s weight-for-age percentile has dropped, this is a red flag to take a closer look and see if breastfeeding dynamics can be improved.  

References

1Mohrbacher, N.  Breastfeeding Answers Made Simple: A Guide for Helping Mothers.  Amarillo, TX: Hale Publishing, 2010.

2Sachs, M., Dykes, F., & Carter, B. Feeding by numbers: an ethnographic study of how breastfeeding women understand their babies' weight charts.Int Breastfeed J 2006; 1:29.

Should Milk Sharing Among Mothers Be Encouraged?

My guest poster today is Karleen Gribble, PhD, Adjunct Research Fellow in the School of Nursing and Midwifery at the University of Western Sydney in Australia.  She also serves as one of Lactnet's listmoms and is well-known worldwide for her research and writing on adoptive and long-term breastfeeding, the risks of formula-feeding, and infant feeding in emergencies.  Thank you, Karleen, for weighing in on this hot topic.

The recent launch of the peer-to-peer breastmilk sharing group Eats on Feets has brought the issue of women sharing human milk to the attention of health authorities. Due to safety concerns, organisations such as Health Canada and the U.S. Food and Drug Administration have warned mothers not to use another woman’s breastmilk unless it comes from a milk bank. Individuals associated with milk banking have gone so far as to describe peer-to-peer milk sharing as “very unsafe” and “dangerous”

The discussion about peer-to-peer milk sharing has much in common with the discourse that surrounds bed sharing. We know many mothers bring their baby into bed with them at night.1 Bed sharing makes breastfeeding easier2 and breastfeeding mothers get more  sleep.3  It also allows mother-baby interaction to continue throughout the night and may protect the infant against the long periods of deep sleep thought to contribute to SIDS.4,5

However, we also know that bed sharing is not always safe. We know that if a mother smokes, if she has consumed alcohol or other sedatives, if the baby is formula fed, if the sleep surface is a sofa or water bed, or if the bed is also shared with other children that a baby sleeping with his or her mother is at heightened risk of SIDS or accidental death. Infant deaths that occurred as a result of bed sharing under these circumstances have resulted in health authorities such as the American Academy of Pediatrics recommending that parents not sleep with their infants.6  It is ironic that not only does blanket condemnation of bed sharing potentially make parenting unnecessarily more difficult for some mothers, it also has the unintended outcome of increasing deaths in places other than beds, such as sofas. This has occurred because due to fears of falling asleep while feeding in bed, some mothers have gotten up to feed on a sofa, fallen asleep there, and infants have died as a result.7,8 Thus, it seems that bed sharing should not be promoted nor condemned.  Rather, parents should be given information about how to bed share safely as well as its risks so they can examine their individual circumstances and decide for themselves where their baby sleeps.

It’s much the same with milk sharing. There is a growing awareness of the importance of breastmilk to the normal health, growth and development of children and of the unavoidable risks associated with the use of infant formula. There are also women who are unable to provide their child with all the breastmilk they require because they have had breast reduction surgery or a double mastectomy or because they have insufficient glandular tissue or are extremely ill. These women have the choice of either obtaining breastmilk from peers or using infant formula. Health authorities who have condemned peer-to-peer milk sharing have told these mothers to obtain human milk from milk banks.  But banked donor milk is an extremely rare commodity available to only a tiny number of (usually hospitalised) infants.

The only real alternative to obtaining human milk from a peer is using infant formula, and the evidence for short- and long-term negative impacts on infants from exposure to infant formula is overwhelming.9 It is interesting that the same health authorities who condemn peer-to-peer milk sharing have not condemned the use of infant formula.  One wonders why the risks of formula are somehow more acceptable than the risks of milk sharing.  Is it because formula feeding is so entrenched in our cultures, while breastfeeding remains marginalised? It is ironic that nearly all of the risks Health Canada identified as applying to breastmilk from a peer (http://www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/_2010/2010_202-eng.php) also apply to infant formula.  But a similar health advisory on the use of infant formula does not exist.

Milk sharing allows mothers to avoid the risks associated with formula feeding.  For some this may be particularly important, for example, those with a family history of diseases associated with formula feeding (diabetes or asthma), the death of a formula-fed baby from necrotising enterocolitis or SIDS, or a baby with formula intolerance.  In most cases, milk sharing is not something a woman does lightly or without good reason. For one mother’s story, click here. 

When mothers use human milk, they avoid the risks associated with infant formula.  However, they potentially expose their child to a whole different set of risks. Fortunately, most of these risks are manageable and some very easily eliminated altogether.  (Although very few diseases can be transmitted via breastmilk, one of them is HIV.  Fortunately, however, a simple home pasteurisation process destroys HIV.10) The Eats on Feets website provides extensive information on managing and minimising risks associated with peer-to-peer milk sharing.

As with bed-sharing, peer-to-peer milk sharing should not receive either a blanket endorsement or condemnation, because the safety of the practice depends very much on the situation.  An alternative to endorsing or condemning it is to acknowledge the reasons women want to milk share (banked donor milk unavailable, infant formula deficient), provide information on how to  manage the risks (recognising that the risks are manageable) and affirm that it’s the parents’ decision.  Just as with bed-sharing, as James McKenna noted:  “It remains the right of parents to make informed decisions, which requires access to unbiased information exchanged within an appropriately relaxed and non-judgmental educational venue.”5

1Rigda, R.S., I.C. McMillen, & Bucley, P.  Bed sharing patterns in a cohort of Australian infants during the first six months after birth. J Paediatr Child Health 2000; 36(2):117-121.

2Blair, P.S., J. Heron, & Fleming, P.J.  Relationship between bed sharing and breastfeeding: Longitudinal, population-based analysis. Pediatrics 2010; peds.2010-1277.

3Quillin, S.I.M. & Glenn,L.L. Interaction Between Feeding Method and Co-Sleeping on Maternal-Newborn Sleep. JOGNN 2004; 33(5): 580-88.

4McKenna, J.J. & Mosko, S.S. Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine. Acta Paediatr Suppl  1994; 397:94-102.

5McKenna, J.J. & McDade,T. Why babies should never sleep alone: a review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding. Paediatr Resp Rev 2005; 6(2): p. 134-152.

6Task Force on Sudden Infant Death Syndrome, The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk.Pediatrics 2005; 116(5):1245-55.

7Blair, P.S., et al., Major epidemiological changes in sudden infant death syndrome: a 20-year population-based study in the UK.  Lancet 2006; 367(9507):314-319.

8UNICEF Baby Friendly, U.K., New research reveals a four fold increase in babies dying when co-sleeping on a sofa, in Baby Friendly News. 2006.

9Ip, S., et al., Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, in Evidence Report/Technology Assessment No. 153. 2007, Agency for Healthcare Research and Quality: Rockville, MD.

10Jeffery, B.S., et al., Determination of the effectiveness of inactivation of human immunodeficiency virus by Pretoria pasteurization.J Trop Pediatr 2001; 47(6): p. 345-49.